Rowan Garth Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to inadequate. This meant people were not safe and were at risk of avoidable harm. The provider was in breach of the legal regulations safe care and treatment and staffing.

This service scored 28 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not have a proactive and positive culture of safety. Lessons were not always learnt to continually identify and embed good practice.

There was a system in place to enable staff to record when accidents and incidents occurred and the action taken. There was however little effective managerial oversight or monitoring of accident and incident information to identify trends in how and when accident and incidents occurred, the effectiveness of the action taken or any evidence learning on how to mitigate the risk of a similar accident and incident occurring again, was shared with staff.

Managerial audits of service delivery showed repetitive shortfalls in assessment, care planning, medicines management, staffing, environment, record keeping, infection control,staff management and governance over a period of 7 months, with little improvement being made. This did not demonstrate a proactive learning or improvement culture was embedded within the service by the provider.

The provider did not establish and maintain safe systems of care to ensure people’s safety was managed and monitored. They did not make sure there was continuity of care, including when people moved between different services or needed support from different health care partners.

People’s needs were not always assessed prior to admission to enable a smooth transition to the home or to ensure staff could meet their needs prior to moving in. This placed people at risk of inappropriate, unsafe care on admission.

People’s needs, risks and care were also not adequately assessed after admission, or for a significant period of time following their admission to the home. For example, some people’s needs had not been properly assessed until 7 months after admission to the home. This meant staff lacked critical information about people’s needs, risks and the care they required, for prolonged periods of time which exposed them to the ongoing risk of avoidable harm.

The information on people’s needs, risk and care subsequently provided to staff, was found to be inaccurate and insufficient. This failure to ensure people’s care was safely planned and managed placed them at serious risk of harm. It would have also significantly and negatively impacted on the person’s safety and effective transition to other services if needed.

The provider did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Some people lived with anxiety and distress which negatively affected their behaviour towards other people and staff. Incident records showed a pattern of similar adverse incidents causing physical or emotional harm to either the person themselves or others. Despite this, there was little evidence any effective action was taken to mitigate the risk of these behaviours occurring again to ensure people’s right to live in safety was protected.

Accident and incidents were recorded on the provider’s electronic system by staff as and when they occurred. Although staff members knew how to report an accident or incident using the provider’s system, some staff members did not have an understanding of different types of potential abuse. This increased the risk of staff not recognising potential abuse so protective action could be taken.

We reviewed a sample of accident and incident records. Records documented the action taken at the time of the accident and incident to protect people from harm. For example, we could see medical advice was sought appropriately when required. Accidents and incidents were reported appropriately to the local authority safeguarding team and CQC.

People told us they felt safe with the staff supporting them and said staff were kind and caring.

The provider did not work well with people to understand and manage risks. Staff did not have adequate or accurate information on people risks or guidance to ensure people’s care was safe, supportive and enabled people to do the things that mattered to them.

People were exposed to the risk of harm, as people’s needs and risks were not properly assessed and staff lacked adequate guidance on how to mitigate risks to their health and welfare.

Some people lived with complex health conditions such as stroke, epilepsy, Parkinson’s disease, diabetes and heart failure. Despite, this, there was a lack of appropriate health and treatment plans in place to advise staff how to meet their clinical needs and risks. For example, staff lacked information on how the condition presented, its impact on people’s lives, the signs and symptoms to spot in the event of ill-health, the action to take to prevent avoidable harm and the care people required. This exposed people to the risk of unsafe, inappropriate care and avoidable harm.

Some people lived with mental health conditions which caused anxiety, distress and behaviours of concern which placed them and others at risk of avoidable harm. The risk assessments and care plans in place failed to give sufficient information on what may cause each person to become distressed, potential triggers, early warning signs and offered little person-centred guidance on how to reduce people’s distress and promote their well-being.

Some people had individual risks associated with falls, skin integrity, eating and drinking, moving and handling, wounds continence, bowel health, pain, anxiety, and distressed behaviours. These individual risks were also not properly assessed and staff lacked crucial and robust information on how to mitigate these risks in the delivery of care. For example, one person had a pressure wound in place. No wound risk assessment had been completed to determine the type, location, condition, size and severity of the wound. There was no wound management plan to provide staff with guidance on the care this wound required or how to prevent further deterioration. There was no evidence professional advice from the tissue viability or district nurse team had been sought and when asked neither the registered manager nor unit manager were aware this person had developed a wound.

In addition, information on people’s needs and risks was often contradictory and inaccurate. For example, one person’s risk assessments gave three completely different sets of information about the person’s ability to hear ranging from a major hearing impairment, a partial impairment to no hearing impairment at all.

The provider did not detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

During our assessment the environment in which people lived, and the equipment used was not always in a good state of repair. Some bedroom walls had holes in, there were broken plug sockets in some rooms, peeling veneer around bedroom sinks, and exposed piping and woodwork in some bedrooms and bathrooms. Communal bathrooms in one unit did not have bath hoists/chairs to enable people to transfer into and out of the bath safely. This meant they could not have a bath if they wanted one. Some areas of the home were also malodorous.

The provider’s service improvement plan showed concerns with the home’s call bell system were identified in January 2025. Feedback from staff corroborated this. Their comments included, “We have had an issue, not been working for 1.5 years, it’s not effective” and “It’s not been working, for a couple of months, they are repairing it”. At the time of CQC’s assessment 6 months later, no robust action had been taken to change or improve the system in place.

Some call bell units in people’s bedrooms were placed in a holder on the wall high up behind their beds. These units did not have call bell leads attached to enable people to access and activate the call bell button when they were in bed or sat in a chair. Some emergency call bell cords in communal toilets and bathrooms were not in place or were out of reach hindering people’s ability to call for help. When pressed the call bell system was difficult to hear especially in communal areas and some staff were observed not to respond to call bells in a timely manner.

People’s environment did not positively support people living with dementia to maintain their independence. Dementia friendly signage and supporting décor to help people navigate around the home and to identify their own bedrooms was poor. For example, there were no directional arrows or signs to show which way the communal lounge was or focal points to enable them to identify where about they were in the home.

People had framed photographs of them on the outside wall of their bedrooms to help them identify their own bedroom. Some photographs however had been taken with other people living in the home or visitors, which made the visual cues and intended association with the person and their own bedroom confusing. Furthermore, people living with dementia can often struggle to identify themselves in photographs, as the condition often impairs facial recognition.

The provider did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and were deployed appropriately. They did not always work together well to provide safe care that met people’s individual needs.

The organisational tools used by the provider to determine safe staffing levels were not based on robust or reliable information about people’s needs. This meant the provider could not be assured the number of staff on duty was sufficient to meet them. A review of the staff rotas showed staffing levels in some units was lower than that determined by the provider as safe. For example, Oak and Beech Units were one or more staff members short during 23 May to 5 June 2025.

During our assessment, we found the number of staff on duty was not always sufficient to meet people’s needs. Most staff spoken with confirmed this. An agency nurse told us, “From a nurse’s point of view, there are not enough nurses, agency nurses don’t like coming back. It is too much”. Other staff comments included, “It’s very chaotic. Staffing levels are low. Night has 2 staff, and we need more (Oak Unit); “Some days (enough staff), some days not. Some days there is a shortage” and “Short staffed at night, only 3 on shift in total for 27 residents and staff are knackered”. Care records corroborated this showing significant gaps in some people’s care and treatment.

People had mixed opinions on whether there were enough staff on duty. Comments included, “I think so, seems to be a lot of staff”; “There are enough, but seems to be a high staff turnover of different staff” and “No there isn’t enough, I wait ages for a bed pan”. A relative felt there were enough staff but said some staff, especially agency staff could not speak good English which made it difficult for [Name of Person] to understand them.

Some people told us staff did not always come quickly when they pressed their call bell. Comments included, “Not really, I have to wait a bit at night time”; “No they say they are too busy” and “I am not sure because I don’t need them (call bell), but sometimes people shout all night”. During our assessment we observed a lack of response from some staff when people rang their call bell to ring for help. Some call bells were ringing for 15 to 20 minutes before being answered. On two occasions, inspectors had to seek staff support for people who were shouting for help in their bedrooms. This did not show staffing levels and staff deployment was effective or safe.

Most staff felt their line manager was approachable and easy to talk to. However, staff had not always received regular supervision from their line manager to support them in their job role. They had also not received an annual appraisal of their skills and abilities for the provider to be assured of their competency.

Staff were recruited safely to ensure persons employed were safe to work with vulnerable people. The provider had a mandatory training and induction programme for all staff to complete. Training was refreshed at specified intervals. Most staff had completed adequate training for their job role, although some staff needed to complete refresher training in topics such as urinary incontinence, basic life support, fire drills and moving and handling.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of the spread of infection by ensuring best practice guidance was followed.

Appropriate infection control and prevention procedures were not in place to ensure clinical or offensive waste was stored and disposed of safely. The provider had an environmental and waste management policy, but this had not been followed.

The provider’s clinical waste bins were not locked or stored securely in accordance with best practice guidelines to prevent unauthorised access. Used personal and protective equipment (PPE) such as gloves and aprons used in the delivery of personal care were found discarded in the home’s car park and surrounding areas, increasing infection and environmental risks.

PPE and people’s personal continence items were not stored appropriately in clean, organised cupboards or containers in their original packaging to protect them from contamination and damage.

Standards of cleanliness within the home were not always satisfactory. Some of the home’s shared equipment was dirty and had not been cleaned between use. For example, we found dirty pressure cushions, moving and handling equipment and shower chairs in communal bathrooms. This failure to ensure the equipment in use was decontaminated appropriately increased the risk of the spread of infection. Some people’s fall mats placed by their beds to minimise the impact of a fall were also unclean.

Legionella bacteria commonly found in water supplies, can expose people to the risk of contracting Legionnaires disease. Legionnaires' disease isa serious type of pneumonia. Providers have a legal responsibility to identify, assess and manage the risk of Legionella by ensuring a range of control measures are in place such as water temperature checks, flushing of infrequently used outlets and the disinfection of showerheads. Whilst we saw the provider’s water supply had recently been tested by an external provider with no Legionella bacteria detected, records showed the required control measures to monitor and manage the risk of Legionella developing had not been followed by the provider.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Time critical medicines including those prescribed for Parkinson’s disease, were not administered at appropriate times. For example, one person was given their medicine 3.5 hours after the required time. This exposed people to the unwanted and often painful or uncomfortable symptoms these medicines were prescribed to treat.

Care plans lacked clear guidance on people’s clinical risks and medicine requirements with regards to epilepsy and diabetes to ensure medicines were given safely and as required. For example, some people’s diabetes care plans contained contradictory information on when to take their blood sugar to ensure the administration of insulin was safe. Records showed people’s blood sugars were not monitored at the recommended frequency and guidance given to staff on when to seek medical advice for high blood sugars was not always safe which placed people at significant risk of serious harm.

Guidance on how to support other medical conditions was also poor. For example, one person was prescribed blood thinning medicine to prevent blood clots but had no care plan outlining the risks associated with this medicine. This meant that staff were not supported to understand or manage the potential side effects or complications of taking this medicine, such as bleeding and bruising.

Controlled drugs were not administered in a timely manner which meant evening doses of this medicine were being given very late, with some people woken up after 11pm to receive this vital medication. This was not good practice and did not promote person centred care and treatment. The checks in place to ensure controlled drugs were given correctly and could be accounted for, varied across the three units.In one unit, the CD stock logbook was not used to do balance checks as per the provider’s procedures.

Protocols for administering people’s as and when required medicines, such as painkillers lacked sufficient guidance on when to administer the medicine, how to assess its effectiveness and what action to take if it was not. Creams were not applied as prescribed, and some creams were found in people’s rooms with no readable prescription labels attached.

Important information about medicine allergies were not accurately recorded for staff to be aware of. This exposed people to the risk of being given a medicine they were allergic too. There was also a lack of adequate information on the type and severity of the allergic reaction people experienced and the action to take. The fire risk associated with the use paraffin-based emollient creams was not always assessed and recorded in care plans. However once this was brought to the providers attention, this was addressed before the end of CQC’s assessment.

Medicines were not always stored at the right temperatures to ensure they would be safe and effective to use. During the medicines round, the medicines trolley was cluttered and untidy, which increased the risk of medicine errors being made and compromising infection control.